Wednesday, June 25, 2014

Thoughts about Assisted Fertility

I met my husband a month shy of my 37th birthday. Four or so years before, I had made a decision that if I
hit 37 without a partner, I would start looking into having a child
by myself. In a way, I met J. at the worst possible time in that
timeline: too late to let us have a baby during my (more) fertile
30s, too early to have begun the process of child-having by myself.
So, we were stuck, fertility-wise. After dating for a while, and an
engagement, we would end up thinking about child-having only when I
was nearing 40.

We knew we could hit some bumps, or
even were likely to hit some bumps. In the end, trying to have a
child dominated the first years of our marriage. We were in pain
often. With most of our friends either already parents or having
children, we felt alone most of the time.

As we went through the process, I
wished most for validation, information, and the opportunity for
conversation. The web offered some of this, but it was also
impersonal, hard to navigate, and overwhelming. I needed personal
teachers and coaches. As the months went on and I talked more about
this with people I often heard of different individuals who had
similar experiences, and that was incredibly helpful, but a community
and such individuals in the same place were also too hard to find and
often without invitation to approach.

This, then, is a list of the decisions
that we made, of what happened and what we did and why, and of how it
felt, shared with deliberate hope that through social media, it is
spread widely to the benefit of others. If anyone reading this wants
to email or call to talk more, I (and we, with my husband) are happy
to do that.

(Note: This is not to say that what we
did was right and everyone else is wrong. This is simply one image of
how all of this worked for one couple, meant as a source for
information, not a set of recommendations.)

It took us about eight months to
get pregnant the first time. We felt lucky that we could get
pregnant. But when the pregnancy ended after ten days (3.5 weeks in
pregnancy terms), our luck did not matter – getting pregnant and
staying pregnant, we felt, were two different things.

That first miscarriage was
shocking. It had occurred to me that I might not get pregnant but
not that I would lose pregnancies. I didn't know very many people
who had lost pregnancies (I thought). I was devastated for weeks and
found it hard to be around couples with kids. I went to a baby
naming of a dear friend and basically ran out after the ceremony, my
husband screening me from well-meaning friends. I began therapy. I
began yoga. I tried to find things to distract me.

It was a year of tracking
ovulation and feeling overwhelmed by uncertainty and failure when we
began to look at IVF. We went to the two primary clinics in San
Francisco, the local teaching hospital and a clinic that
reminded me of the office in the TV show Private Practice, with
cucumber water and a sweeping view of the Pacific Ocean and
Alcatraz. At the private clinic, we saw a doctor that my therapist
recommended, who wanted to move immediately to IVF. We liked him; he
was to-the-point and rooted his ideas in empirical data. But we were
not sure that we wanted to move immediately to IVF and wanted to
talk options. He was reluctant. I saw an acquaintance in a grocery
store and spilled all of this to her—did we want to do IVF? Did
we trust this doctor?—and she reminded me that if we didn't feel
comfortable with the doctor, we should go somewhere else. Also, I
didn't need the cucumber water, and the other clinic was down the
block from our house. It was just logistically easier to get to the
teaching hospital, and this wasn't unimportant.

At the same time, we made phone
appointments with everyone we knew who had challenges with unwanted
fertility. We asked them to walk us through their stories and their
decisions. Even once we knew what we would probably do, it was
incredibly helpful. We began to understand the various routes
through this maze, the extent to which there are different options,
and how many stops there might be in this experience before we
actually get to “baby,” to the real goal.

The phone appointments were
helpful also because we got to spend time talking about this – and
we needed time to talk, reflect, and process. We carried this story
with us all the time, but interacted with most of our friends around
regular life stuff. The details of what it felt like to be engaged
in this project, or to carry pregnancy loss around – it didn't
feel like anyone wanted to hear. Often I felt that I was living two
lives, one in our apartment with my husband, and one public life
with friends and colleagues.

During this process, I began to
realize how tentatively I was making decisions. I looked frequently
to others for information and validation. (When a story ran in the
local Jewish paper about a memory garden for fetal loss, I called a
few of the principals involved in the story to ask them how they
chose their fertility clinic.) Perhaps my most significant lesson
learned from all of this is that I was constantly looking for the
best answer – which doctor to choose, which intervention to try –
but I'm not sure there are any best answers, and I found few right
answers. Given my temperament, this was incredibly hard for me to
live with. (I knew it would continue to be hard through pregnancy
and parenting, and sure enough, it has been.)

At the same time that we went to
the private fertility clinic, we went to a public information
session at the teaching hospital. This was an incredibly detailed
introduction to IVF, meant more for individuals who were beginning
the IVF process and less for those considering their options. It was
cold and highly medicalized. I left terrified and strongly
considering adoption. I could not imagine putting my body through
the shots, the procedures, and the influx of drugs. Somehow, I
accepted that if I wanted a biological child – and for whatever
reason, I did, although I did some soul searching on this, too –
this would be the path. It took a period of acceptance, though, that
lasted, truthfully, until I was pregnant.

A first step in the IVF process is
checking to see how many follicles a woman grows during a typical
menstrual cycle. Just after we did that at the private clinic, I got
pregnant a second time. I was terrified and also incredibly
nauseated. I was pregnant for about ten weeks. I spent most of that
time on my couch, trying to get work done, but mostly hiding. I was
scared to be happy, scared to talk to friends because I didn't want
to tell them I was pregnant (and then have to untell them), and
physically ill.

We found out that the pregnancy
wasn't viable when we went for a typical 10 week OB appointment and
a kind midwife scheduled us for an ultrasound (medically
unnecessary, but imperative to our sense of calm) the next day.
Serendipitously, there was no heartbeat; the pregnancy had probably
ended a few days before. I was turning 40 that weekend. On the way
home from the ultrasound, my husband told me about the surprise
party he had planned. We went for our annual birthday hike to the
beach talking about our options, and I remember trying not to focus
on the cells inside me that were no longer alive. I had a D&E the following week rather than wait for them to leave spontaneously.

We immediately scheduled an
appointment not at the private clinic but at the teaching hospital,
with a doctor who friends were seeing who specialized in first
trimester miscarriage. On the off-chance that this wasn't
age-related, we wanted someone who could help us address other
possible causes. We got an appointment for ten weeks after the
miscarriage, which seemed a lifetime later. In retrospect, my body
needed a chance to heal, but emotionally, those ten weeks were
exhausting.

I began also to look at other
therapies, particularly at stories of individuals who became
pregnant through non-medical means, using acupuncture, food, yoga,
etc. And, I tried to learn about medical practitioners who work on
fertility using means other than ART. Ultimately, I began
acupuncture and tried to be careful about what I ate – no
caffeine, alcohol, lots of vegetables – but I drew the line at
wheatgrass and daily yoga for fertility. I was making myself crazy
with the possibilities, that is, with all of the work I could be
doing to strengthen the quality of my eggs. And, the
unpredictability of it was hard: There was only vague research
demonstrating the links between these therapies and fertility
success, and even the practitioners themselves suggested that the
therapies were not foolproof. When the therapies started to make me
feel more bad than good, I started ignoring them.

We met with the doctor at the
teaching hospital. We immediately felt comfortable with her and
appreciated that she did not see us as having only one course of
action but instead laid out options and related chances of success.
By then, though, we felt that we would do anything to lower the
chances of another miscarriage. After some thought, we decided to
throw all the resources we could at having a healthy baby in as few
tries as possible. This would be expensive – IVF with
pre-screening of embryos – but it would buy our mental health in a
way that an IUI cycle, with lower chances of success and higher
chances of an embryo implanting that would be genetically
non-survivable, would not.

In retrospect, the actual IVF
cycle went quickly. At the time, particularly as we began the cycle,
all I could feel was fear: at the shots, at building my work
schedule around it, at it failing. I'm not sure that I ever got used
to the entire effort of shots and daily ultrasounds.

In fact, I doubted the project the
entire time, wondering if we were spending money needlessly, if we
should have stuck with natural methods and been patient. I wish I
could have been nicer to myself. We had made a decision that
optimized our chances to have a baby. It was expensive and
emotionally and physically challenging. It wasn't the only decision
we could have made. But it wasn't the wrong decision, by any means.

We did two cycles of egg
retrieval, one after the other, before we did any kind of embryo
transfer. We decided that we wanted to optimize our chances for a
baby and that we wanted as many embryos as possible when I was as
young as possible. On the other hand, we didn't have unlimited
resources and couldn't see doing more than two cycles. Both cycles
together produced four healthy embryos. Many eggs (follicles) were
retrieved, producing a total of 13 embryos with both cycles (My
problem was not that I had very few eggs but that the egg quality
was poor). Those 13 went to the screening clinic, and four were
genetically stable. I felt incredibly blessed to have four but was
also thrown by the number: With only four out of thirteen embryos
being sound, it seemed validation that if we had tried to have a
baby naturally, we would have likely had miscarriage after
miscarriage.

We couldn't implant an embryo for
another three months, until after I had a small procedure and
healed. That was a bit of a surprise, and we felt that our clinic
did not handle communication around this as well as they might have
(this is an understatement). We didn't trust our nurse after that
(and actually insisted on switching nurses) and I was miserable,
bitter and resentful. We tried to distract ourselves during the
three months. I declared it the “Summer of Food” and got
reservations at good restaurants with lots of different girlfriends.
We took vacations and tried to ignore the thing that seemed to be
hanging over us.

When we started to get ready for
the embryo transfer, taking the shots and so on, it seemed
anti-climactic. The shots were more intense but fewer and there were
many fewer office visits. The procedure itself was minor. I stressed
repeatedly about all of it: How could I maximize this opportunity to
get pregnant? What should I be eating, or doing, that day and the
weeks before? When should I get acupuncture? How much bed rest
should I plan for? Could I exercise? There were not straight answers
to any of these questions and I obsessed and obsessed, searching the
internet and calling friends. I finally realized that, again, there
was no clear path and that, ultimately, I was trying to control
something that was uncontrollable. I decided to pamper myself the
day of the procedure, going to yoga, getting a facial, and going to
a favorite restaurant with my husband. It was the right decision:
Going into the procedure I was more relaxed than I had been in
months.

The two-week-wait seems like a
blur, a mix of activity – planned deliberately – and moments of
anxiety and internet-googling to look for hints that I was pregnant.
Ultimately, when I was told that I was pregnant (told, ha, I also
took a pregnancy test in a coffee-shop bathroom, shaking when I saw
that it was positive), I was surprised not to feel only joy, to feel
that we still weren't at the end. There were more blood tests and a
first trimester to get through, and even though we had screened the
embryo for genetic abnormalities, the screening was not fool-proof.
There was a chance the pregnancy could end. We waited to tell close
friends until after the 20-week ultrasound and waited even longer to
tell others, somewhat convinced that this wasn't really happening.

Ultimately, I was nervous for about
thirty weeks, or maybe even until he was delivered, to the point
where when I entered large rooms of colleagues and acquaintances,
obviously pregnant, I was aware that in three months I might have to
share bad news. I waited to write this piece, even, until after his
delivery – the worst time to write! - because I was not convinced
that this experience with infertility is over.

In many ways, though, it is over, and
that feels incredibly strange. We were very lucky in that our
experience was relatively short and resulted in the goal: a baby. The
pain of the miscarriages and the uncertainty of the process are paled
by the joy I now feel at holding my baby in my arms. At the same
time, the pain hasn't gone away. This is part of me, part of our
story and of our child's story. I feel acutely aware that if we go
for #2, we will enter this project and its uncertainty and physical
stress again. And I know that we were lucky much more than we were unlucky.

A friend shared his own mantra in the
middle of this project: It will be okay in the end. If it's not okay,
it's not the end. (He added – It's not a competition, and, It won't
end how you think it will.) It kept me going, often. We would find
our “okay,” somehow. And we did, in our healthy baby, but also in
that I'm almost okay with this being part of our story. I've almost
accepted that this is where we've been, where we are, and I get now
that time will continue to help and heal.

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introduction

Beth Cousens Consulting supports non-profit organizations by leading strategic evaluation and research services, helping organizational leaders to clarify organizational vision, strategy, and indicators of success, supporting educational leaders through coaching and training, and strengthening through research the practice of teaching and learning in Jewish settings.

Our societies today face challenges significant and complex. Addressing them requires each of our best creativity and passion. More than that, we need to work together, to intertwine our chochmat halevevot, the wisdom of our hearts, to trust each other, to help each other identify our strengths and our wisdoms, to develop the capacity to be vulnerable and to take public risks. This requires self-knowledge and simultaneous confidence and humility, confidence enough to know that one does not need to provide an answer in order to be in the game, humility enough to acknowledge that rarely do we have the right (or only) way to address a challenge.

Beth Cousens Consulting works with clients on these issues from a place of insight, rigor, and creativity, vulnerability, curiosity, and partnership, bringing ideas and results that lead to organizational and communal growth.

We respond to society’s challenges from within a rich Jewish ecology, from which we celebrate a vibrant Jewish life. We turn to our tradition for inspiration, community, challenge, and texture. We understand Judaism as a living tradition that has been interpreted and reinterpreted countless times; we encourage every student of Jewish life to find her own relationship to Judaism and her own place in the Jewish narrative.

Beth Cousens holds a PhD in the Sociology of Jewish Education from Brandeis University (2008, matriculation 2001), an MA with honors in Jewish Studies from Baltimore Hebrew University (1996), an MSW from the University of Maryland (1996), and a Certificate in Jewish Communal Service from the Baltimore Institute in Jewish Communal Service (1996). She received a BA (1994) from the University of Michigan in English and Creative Writing.

She has over twenty years of professional leadership experience, working in educational policy and strategy and directly as an educator. She has particular expertise building educational settings that maximize opportunities for individuals to develop as independent Jewish adults, owning their Jewish ideas and practices. Her expertise also focuses on younger (“emerging”) Jewish adults.